The Life Challenge
Facility Sign Up

The Life Challenge (L+C) Program maintains caring, supportive relationships with our members after discharge through a variety of outreach programs. We protect the privacy and confidentiality of all members and promise not to share your personal information with any outside vendors or commercial entities.

 

 

 

 

 

 

 

Birthday

 

Best Time to Contact
MorningAfternoonEvening

 

Best Way to Contact
PhoneEmailTextMail

 

Where Did You Last Attend Treatment?

 

Admission Date

 

Discharge Date

 

 

 

What are 3 challenges you want to accomplish?

 

 

 
By checking this box, you authorize Foundations Recovery Network to contact you after discharge from our treatment program. You also declare that this consent is given freely and voluntarily, and that you understand that your records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR, Part 2, as well as under HIPAA, 45 CFR Parts 160 and 164, and that no information may be re-disclosed by either party to any individual or agency unless by written consent of the patient. You also understand that this authorization may be revoked at any time in the future by written statement.